The experiences of gender diverse and trans children and youth considering and initiating medical interventions in Canadian gender-affirming speciality clinics

Abstract

Background: Canadian specialty clinics offering gender-affirming care to trans and gender diverse children and youth have observed a significant increase in referrals in recent years, but there is a lack of information about the experiences of young people receiving care. Furthermore, treatment protocols governing access to gender-affirming medical interventions remain a topic of debate.

Aims: This qualitative research aims to develop a deeper understanding of experiences of trans youth seeking and receiving gender-affirming care at Canadian specialty clinics, including their goals in accessing care, feelings about care and medical interventions they have undergone, and whether they have any regrets about these interventions.

Methods: The study uses an adapted Grounded Theory methodology from social determinants of health perspective. Thirty-five trans and gender diverse young people aged 9 to 17?years were recruited to participate in semi-structured interviews through the specialty clinics where they had received or were waiting for gender-affirming medical interventions such as puberty blockers, hormone therapy, and surgery.

Results: Young people felt positively overall about the care they had received and the medical interventions they had undergone, with many recounting an improvement in their well-being since starting care. Most commonly shared frustrations concerned delays in accessing interventions due to clinic waiting lists or treatment protocols. Some youth described unwanted medication side-effects and others said they had questioned their transition trajectory at certain moments in the past, but none regretted their choice to undergo the interventions.

Discussion: The results suggest that trans youth and gender diverse children are benefiting from medical gender-affirming care they receive at specialty clinics, providing valuable insight into their decision-making processes in seeking care and specific interventions. Providers might consider adjusting aspects of treatment protocols (such as age restrictions, puberty stage, or mental health assessments) or applying them on a more flexible, case-by-case basis to reduce barriers to access.     

Non-binary youth: Access to gender-affirming primary health care

ABSTRACT

Background: Transgender (trans) youth who identify outside the gender binary are a growing subpopulation. In this article, we document differences in access to gender-affirming health care between binary and non-binary identified trans youth and explore ways of meeting the health needs of non-binary youth within primary care settings.

Methods: The Canadian Trans Youth Health Survey is a national online survey of trans youth, 14–25 years, conducted in 2013–2014. Among the 839 participants who responded to gender identity items in the survey, 41% identified as non-binary. We compared demographic, health outcome, and health care access responses between non-binary and binary (trans girls/women and trans boys/men) youth.

Results: Non-binary and binary youth were similar in most demographics, including age, geographic distribution, and ethnocultural backgrounds, however a larger proportion (82%) of non-binary youth were assigned female at birth. Older non-binary youth (aged 19–25) were significantly more likely to forego needed healthcare than older binary youth; no significant differences were found between younger (14–18) non-binary and binary youth in foregoing healthcare. Overall, non-binary youth (13%) were significantly less likely than binary youth (52%) to access hormone therapy, but they were more likely than binary youth to report experiencing barriers to accessing hormone therapy when needed.

Conclusions: Non-binary trans youth in Canada report challenges in accessing needed gender-affirming healthcare. Primary care providers are well-situated to integrate a broad range of gender-affirming care services into practice in order to address the unique needs of non-binary youth. Future research is warranted to explore experiences of non-binary youth related to barriers to care and to explore how services can be designed and delivered to better meet the needs of non-binary youth seeking gender-affirming primary care.     

Considerations on medical training for gender-affirming care: Motivations and perspectives

Abstract

Background: Many transgender individuals lack access to needed medical care, partially due to a lack of providers with experience in gender-affirming healthcare.

Aims: The purpose of this study was to identify professional motivators for medical providers seeking out training in gender-affirming care and to define which training experiences were most beneficial to their career development. By identifying experienced providers’ recommendations on which training modalities are most relevant to their practice, we aim to suggest future directions for medical education initiatives to effectively expand the transgender care workforce.

Methods: A voluntary cross-sectional electronic survey was distributed through professional listservs and publicly-available referral lists to interdisciplinary providers who self-identified as having experience in providing care to transgender individuals.

Results: One hundred and fifty-three (n?=?153) physicians, physician assistants, or advance-practice nurses responded to the survey. The majority (96.7%) were located in the United States, representing 37 states. The two most common motivators for seeking out training in gender-affirming care were filling a need in the community (73.0%) and/or having met a transgender-identified person in a clinical setting who requested care (63.8%). While many providers gained skills independently (57.3%), the two most commonly-available training opportunities were professional conferences (57.3%) and mentorship (41.3%). Respondents were most likely to recommend that others in their field be trained via structured clinical experience (e.g., a rotation or longitudinal exposure during training), rather than additional didactic training.

Discussion: This study identifies key high-yield training methodologies which could improve access to quality gender-affirming healthcare. Through integration of structured clinical experiences during training, direct clinical mentorship, and professional development at conferences on gender-affirming care, the workforce of welcoming and prepared healthcare providers for transgender patients will increase. This will lead to a tremendous improvement on access to gender-affirming care in our communities.     

“I knew that I wasn’t cis,I knew that,but I didn’t know exactly”: Gender identity development,expression and affirmation in youth who access gender affirming medical care

Abstract

Background: Research about gender identity development is still in its infancy, especially among youth who experience gender dysphoria and are accessing gender-affirming medical care.

Aims: This article contributes to the literature on how gender identity and gender dysphoria is experienced, expressed and addressed by youth who have started, or are just about to start, a gender-affirming medical intervention.

Methods: The project draws from qualitative interviews with 36 trans children and youth of different ages and stages of puberty. The data were collected in three specialized Canadian clinics that offer gender-affirming care and they were analyzed through inductive thematic analysis.

Results: Two interlinked dimensions of the youth’s lives allow meaning-making of their gender identity: 1) internal or personal and 2) interactional or social processes. Careful analysis reveals three gender identity development pathways that may be taken by youth, from early questioning to the affirmation of their gender identity. A discussion of current models of gender identity development and their limitations concludes the article.     

I'm more driven now: Resilience and resistance among transgender and gender expansive youth and young adults experiencing homelessness

ABSTRACT

Background: Little is known about the resilience strategies of transgender and gender expansive youth and young adults (YYA) experiencing homelessness. In addition to difficulties accessing trans-affirming supports and services, transgender and gender expansive YYA must contend with structural constraints and oppressive messages about who they are and who they can become. Despite these challenges, transgender and gender expansive YYA experiencing homelessness are finding innovative ways to resist the multiple and overlapping institutionalized challenges they face.

Methods: This qualitative study examined the ways a group of transgender and gender expansive YYA demonstrate resilience and resist dominant narratives about what it means to be young, transgender and experiencing homelessness.

Results: Two primary themes were identified through which transgender and gender expansive YYA experiencing homelessness demonstrated resilience in the midst of structural constraints and oppressive narratives about who they are and who they can become: personal agency and future orientation. Participants exercised personal agency through self-definition and making their own choices. They oriented themselves to future possibilities through positive meaning-making and re-visioning the meaning of home. Participants engaged in these acts of resilience and resistance despite receiving negative messages about themselves.

Conclusions: Study findings illustrate the capacity of transgender and gender expansive YYA experiencing homelessness to reframe their challenges as positive experiences, integral to the people they have become or will be in the future. Findings point to the need to expand conceptualizations about people experiencing homelessness, and to utilize a strengths-based framework in practice and research.     

Common barriers to healthcare for transgender people in the U.S. Southeast

Abstract

Background: Transgender and non-binary people are more likely to face barriers to healthcare than their cisgender counterparts. The majority of work in this area centers on the experiences of transgender people in northern cities and urban enclaves, yet over 500,000 transgender people live in the U.S. Southeast.

Aims: The purpose of this study is to explore barriers to healthcare among transgender people in the U.S. Southeast.

Methods: The research team conducted four 120-minute focus groups (eligibility criteria: 18?years or older, self-identify as transgender, live in the U.S. Southeast). Participants completed a demographic questionnaire prior to the start of the focus group. Each focus group explored access to and experiences of receiving basic healthcare as a transgender person in the U.S. Southeast. Established qualitative methods were used to conduct the focus groups and data analysis.

Results: Participants (n?=?48) ranged in age from 19 to 65, with the majority identifying as trans women (43.8%) and non-binary (33.3%). The sample was racially diverse: White (50%), Black (37.5%), and Latinx or Multiracial (12.5%). Multiple barriers to care were identified: (1) fear and mistrust of providers; (2) inconsistency in access to healthcare; (3) disrespect from providers; and, (4) mistreatment due to intersecting experiences of gender, race, class, and location.

Discussion: Transgender Southerners face barriers to care at the structural, cultural, and interpersonal levels. The study results have implications for researchers, as well as providers, practices, and health care systems throughout the region.     

Experiences of transgender prisoners and their knowledge,attitudes, and practices regarding sexual behaviors and HIV/STIs: A systematic review

Background: Despite transgender people being more visible in prison systems, research suggests they are at higher risk of experiencing sexual violence compared to other prisoners. Research also suggests that transgender prisoners experience harassment, and physical and sexual assault by fellow prisoners, and prison officers who lack transgender-specific health knowledge. There exist no systematic reviews on the experiences of transgender people in prisons. This review aims to fill this research gap. The following question developed in consultation with transgender, sexual health/HIV and corrective services stakeholders has guided the systematic review: What are transgender and gender-diverse prisoners’ experiences in various prison settings and what are their knowledge, attitudes and practices regarding sexual behaviors and HIV/STIs?

Methods: The review followed the PRISMA guidelines and searches were conducted in four databases for the period of January 2007 to August 2017. Studies were assessed against predetermined inclusion and exclusion criteria. Included studies were peer-reviewed, written in English with online full-text availability and reported data on transgender and gender-diverse prisoner experiences relevant to the research question.

Results: Eleven studies (nine qualitative, one quantitative, one mixed-methods; nine in USA, two in Australia) met the criteria for review. Four studies were of high quality, six were of good/acceptable quality, and one study was of modest quality. Transgender and gender-diverse prisoners reported a range of challenges which included sexual assault, discrimination, stigma, harassment, and mistreatment. Information on their sexual health and HIV/STIs knowledge, attitudes, practices is in short supply. Also, their lack of access to gender-affirming, sexual health/STIs and mental health services is commonplace.

Conclusions: The experiences of transgender prisoners as reported in this review are almost uniformly more difficult than other prisoners. Their “otherness” is used as a weapon against them by fellow prisoners through intimidation and violence (including sexual) and by prison officers through neglect and ignorance.     

Orchiectomy in transgender individuals: A motivation analysis and report of surgical outcomes

Abstract

Background: Different surgical procedures are available for transgender women wishing to undergo genital gender-affirming surgery.

Aim: To assess preoperative motivations, the frequency of orchiectomy procedures, and postoperative outcomes of orchiectomy in transgender individuals.

Methods: All transgender individuals who underwent orchiectomy in the period between January 2012 and January 2020 at our institution were retrospectively identified. A chart study was conducted, recording motivations, demographics, perioperative characteristics and surgical outcomes. The frequency of orchiectomy and vaginoplasty procedures during the study period were determined and compared.

Results: During the study period, an increase of performed orchiectomy procedures was observed. The orchiectomy/vaginoplasty ratio was 0.01–0.07 in the period 2012–2018 and 0.24 in 2019. A total of 43 transgender individuals were retrospectively identified. Sixteen (37%) initially wished to undergo a vaginoplasty, but did not meet institutional requirements (nonsmoker, BMI < 30kg/m²) or were not eligible for vaginoplasty surgery because of interfering somatic or mental health issues. Fourteen (33%) individuals who underwent orchiectomy regarded it as a preceding step to a future vaginoplasty procedure. Out of these fourteen, one person is now on the waiting list for vaginoplasty surgery. Thirteen (30%) others did not report a desire to pursue vaginoplasty in the future. This was mostly motivated by the absence of genital dysphoria or motivations related to their gender identity, with a desire to discontinue anti-testosterone treatment. The postoperative course was uncomplicated in 39 (91%) individuals.

Conclusion: In the Netherlands, especially in the last year, the frequency of orchiectomy procedures has increased. Reasons that people chose to undergo this procedure include: not being eligible for a vaginoplasty procedure, seeing it as a preceding step to a possible future vaginoplasty or other identity-related motivations (i.e., non-binary gender identification or absence of genital dysphoria).     

The transgender parent: Experiences and constructions of pregnancy and parenthood for transgender men in Australia

Background: Transgender (trans) men are commonly born with the reproductive anatomy that allows them to become pregnant and give birth and many wish to do so. However, little is known about Australian trans men's experiences of desiring parenthood and gestational pregnancy.

Aims: The present study aims to address this gap in the literature through addressing the following research questions: how do Australian trans men construct and experience their desire for parenthood? And, how do Australian trans men construct and experience gestational pregnancy?

Methods: This study aimed to explore these experiences, through a mixed-methods research design using online survey data and one-on-one interviews, with 25 trans men, aged 25–46 years old, who had experienced a gestational pregnancy. Data were analyzed using thematic analysis.

Results: For our participants, parenthood was initially described as alienating and complex, however transitioning enabled participants to negotiate and construct their own parenting identity. Pregnancy was positioned as a problematic but “functional sacrifice,” however formal assisted fertility experiences were rife with exclusion. At the same time dysphoria associated with withdrawing from testosterone and the growing fecund body were significantly troubling. Changes to the chest were of particular concern for participants. Exclusion, isolation, and loneliness were the predominant features of trans men's experiences of gestational pregnancies. Healthcare systems are not generally supportive of trans bodies and identities and trans men encounter significant issues when interacting with healthcare providers. As such, the results reinforce the importance of inclusive and specialized health services to support trans men through pregnancy.     

Experiences with stigmatization among transgender individuals after transition: A qualitative study in the Netherlands

Abstract

Background: Transgender individuals belong to one of the most stigmatized groups in society. Although the social stigma of transgender individuals has been examined many times, post transition stigma experiences among transgender individuals have received limited research attention. The aim of this study was to examine experiences with stigmatization among Dutch transgender individuals after their transition.

Method: Ten trans women (age: M?=?58.50, SD?=?9.49) and 10 trans men (age: M?=?42.90, SD?=?13.62) participated in face-to-face semistructured interviews. Grounded theory was used to conceptualize and analyze the data. We examined the positive and negative reactions that transgender individuals experienced in the period after their transition. Furthermore, we explored differences between experiences of trans men and trans women. Finally, we examined differences between cisgender men and women regarding their reactions toward transgender individuals.

Results: Participants reported improved psychological well-being since transition. However, they still experienced different forms of stigmatization. Trans women appeared to experience stronger social stigma than trans men. Trans women also experienced lower social status after their transition. They mainly experienced negative responses from cisgender men. Participants emphasized the importance of social and peer support.

Conclusion: The current study findings demonstrate the presence of stigmatization after transition and argue for psychological aftercare. Social and peer support appeared to be important for coping with stigmatization, and improving the social network of transgender individuals is beneficial. Health providers and researchers are recommended to promote the development of constructive coping skills for transgender individuals with interventions especially targeting trans women.     

Bullies,blades, and barricades: Practical considerations for working with adolescents expressing concerns regarding gender and identity

ABSTRACT

Background: Adolescents, by their very nature and need for maturity, struggle with issues of the self and identity, while challenging the very systems that are there to support them. However, gender diverse adolescents may become detached and overwhelmed as a trans identity solidifies during this time. Bullies, blades and barricades describes the challenges, hardship and dispossession that some gender diverse adolescents face from interpersonal and intrapersonal conflicts, societal pressure and hostility.

Method: This paper utilizes the current research on safety and risks affecting trans youth, the authors clinical experience of trans and gender diverse adolescents, and recommendations in the literature for professional care and support of gender diverse adolescents to identify the various ways gender diverse adolescents are negatively affected by their experiences.

Results: Bullying is not limited to school or peer environments and may be present in adolescents' homes, in local communities, in professional services or from sources of information such as the media. The physical dangers gender diverse adolescents face may arise from victimization, violence or rejection, or self-harming behaviors due to negative beliefs, fear or frustration. Barriers preventing disclosure and expression of gender and/or identity may stem from negative experiences, rejection, pubertal changes, imposed limitations, dependence upon school, home or legal environments, or other spheres of influence.

Discussion: Affirmative approaches, individual focus, recognition of family dynamics, inclusion of significant others, advocacy in school and local community environments as well as professional training are the most commonly recommended interventions. This paper provides an inclusive review of the myriad of challenges confronting gender diverse adolescents including often unrecognized forms of pressure, oppression and restrictions. This paper aims to support clinicians by contextualizing the adversity that gender diverse adolescents face and offers strategies for engagement and intervention.     

Digging beneath the surface: Results from stage one of a qualitative analysis of factors influencing the well-being of trans youth in Quebec

ABSTRACT

Background: The literature on trans youth has been dominated by etiological studies interested in trans experience as a medical phenomenon. An emerging body of literature has begun to document that trans youth are a diverse, vulnerable, yet resilient population, and to investigate the role of various sites of support such as the family, peer groups, institutions, and community spaces in contributing to or impeding trans youth's well-being.

Method: This article presents the results of Stage One of interviews (n = 24) conducted for a Community-Based Participatory Action Research (CBPAR) qualitative research project based in Quebec. It studies the factors that enhance trans youth's well-being as well as the factors of oppression that negatively affect it. This paper offers a brief overview of the anti-oppressive methodology used for this project, emphasizing how CBPAR was combined with Grounded Theory (GT) methods to encourage the direct involvement of communities and the translation of knowledge into action.

Results: We present preliminary categories emerging through the ongoing axial coding process. These categories address trans youth's experiences in and perceptions of various “sites”: 1) healthcare services both for gender-related and general care, 2) other institutional spaces, 3) the family and other social circles, and 4) community spaces.

Conclusion: While much of this study's results support existing evidence on trans youth's experiences, they also provide a more nuanced portrayal of the complex ways in which recognition, as well as non-, mis-, or mal-recognition, influence trans youth's well-being at different sites. We also argue that recognition itself must be considered through the lens of intersectionality.     

Using circular questions to explore individual family member experiences of youth gender dysphoria in Australia

Abstract

Background: The number of young people reporting gender dysphoria is increasing worldwide, with gender dysphoria known to affect everyone in the family in unique ways. Previous research has highlighted the importance of family support and understanding; however, much less is known about individual and collective family member experiences, particularly for siblings under the age of 18?years.

Aims: This study sought to identify, describe and interpret individual family member experiences of youth gender dysphoria using semi-structured interviews, incorporating circular questioning, within a whole of family, clinical and wider social context.

Methods: Thirty-five individual family members living in Australia (nine young people aged 12-17?years experiencing gender dysphoria, 10 mothers, eight fathers, and eight siblings aged 11-17?years) were interviewed, exploring positive and negative experiences of youth gender dysphoria, within and outside of the family. Family relationships, support and healthcare experiences were also explored.

Results: All participants reported a mixture of positive and negative experiences of youth gender dysphoria. Levels of acceptance tended to change with the duration of transition, with most family members adapting with time. Siblings reported mixed experiences within the same family, with some struggling to adapt. Most family members felt that including the whole family in the healthcare of the young person was important, although dependent on individual circumstances and family context. Specialist gender care experiences were unanimously positive, although services were considered difficult to access.

Discussion: Family members reported shared and individual positive and negative experiences of youth gender dysphoria across social contexts. Accepting and facilitating gender transition for young people appeared to improve individual and family functioning. Most participants valued a whole of family approach within specialist healthcare. The use of circular questioning in the study helped dispel assumptions and facilitated curiosity for others’ experiences in the family.     

Combining total laparoscopic hysterectomy and bilateral salpingo-oophorectomy with subcutaneous mastectomy in trans men: The effect on safety outcomes

Abstract

Background: Masculinizing mastectomy is the most requested gender affirming surgery (GAS) in trans men, followed by genital GAS. Mastectomy and total laparoscopic hysterectomy, with or without bilateral salpingo-oophorectomy (TLH?±?BSO), can both be performed in one single operation session. However, data on complication rates of the combined procedure is scarce and no consensus exists on the preferred order of procedures.

Aims: To compare safety outcomes between mastectomy performed in a single procedure with those when performed in a combined procedure and assess whether the order of procedures matters when they are combined.

Methods: A retrospective chart review was performed of trans men who underwent masculinizing mastectomy with or without TLH?±?BSO in a combined session. The effects of the surgical procedure on complication and reoperation rate of the chest were assessed using logistic regression.

Results: In total, 480 trans men were included in the study. Of these, 212 patients underwent the combined procedure. The gynecological procedure was performed first in 152 (71.7%) patients. In the total sample, postoperative hematoma of the chest occurred in 11.3%; 16% in the combined versus 7.5% in the single mastectomy group (p?=?0.001). Reoperations due to hematoma of the chest were performed in 7.5% of all patients; 10.8% in the combined versus 4.9% in the single mastectomy group (p?=?0.017). The order of procedures in the combined group had no significant effect on postoperative hematoma of the chest (p?=?0.856), and reoperations (p?=?0.689).

Conclusion: Combining masculinizing mastectomy with TLH?±?BSO in one session was associated with significantly more hematoma and reoperations compared with separately performing mastectomy. This increased risk of complications after a combined procedure should be considered when deciding on surgical options. The order of procedures in a combined procedure did not have an effect on safety outcomes.     

Internalized transphobia and mental health among transgender adults: A nationwide cross-sectional survey in South Korea

Abstract

Introduction: Transgender people are stigmatized in South Korea (hereafter Korea), where cultural expectations of a biologically-based, binary sex and gender system present fundamental challenges to those whose gender identity does not align with their birth-assigned sex. A growing international body of literature implicates gender minority stress as a key contributor to transgender mental health disparities, but little research has been conducted on this topic in Korea. As in other cultural settings, depression and suicidality are urgent public health concerns for transgender people in Korea, primarily for those who have not initiated gender affirming medical treatment (GAMT), such as cross-sex hormone therapy. In the current study, an international and interdisciplinary team of authors apply the lens of gender minority stress to elucidate the relationships between a key facet of gender minority stress, internalized transphobia (ITP), and outcomes of depressive symptoms and suicidality.

Methods: Based on a cross-sectional survey of 207 Korean transgender adults, the current study evaluates the relationships between ITP and depressive symptoms, suicidal ideation, and suicide attempts. ITP was measured with an eight-item, Korean-language questionnaire adapted from the Gender Minority Stress and Resilience Measure through a translation and back-translation process.

Results: Korean trans women and trans men mean (mean age?=?26.4) were included in the analysis, most of whom had at least one experience of any GAMT. The findings of this study show that Korean transgender adults face similar public health concerns such as high prevalence of depressive symptoms, suicidal ideation, and suicide attempts. As predicted, ITP was significantly related to depressive symptoms, suicidal ideation, and suicide attempts.

Conclusion: The authors suggest potential clinical, policy, and research applications, including institutional interventions, to address structural and cultural barriers to optimal mental health and GAMT as well as mental health interventions to reduce Korean transgender people’s internalized negative beliefs about their gender identity.     

Student Healthcare Clinicians' Illness Narratives: Professional Identity Development and Relational Practice

ABSTRACT

In this qualitative, grounded theory study we examine how the intersection of self-reflection, illness narratives and perceived messages of professional identity inform care provided by medical, nursing, and medical family therapy students to patients and families. We discovered four common challenges students faced navigating personal experiences of illness and connecting to patients: 1) discrepancies between ideal and lived experiences, 2) challenges of healthcare work and culture, 3) navigating power and hierarchy, and 4) developing a shell of privacy. Discussion and implications include interdisciplinary training and collaboration and the unique role of medical family therapists in healthcare.     

‘I feel better when…’: An analysis of the memory-experience gap for peoples’ estimates of the relationship between health behaviours and experiences

Objective: People often overestimate how strongly behaviours and experiences are related. This memory-experience gap might have important implications for health care settings, which often require people to estimate associations, such as “my mood is better when I exercise”. This study examines how subjective correlation estimates between health behaviours and experiences relate to calculated correlations from online reports and whether subjective estimates are associated with engagement in actual health behaviour.

Design: Seven-month online study on physical activity, sleep, affect and stress, with 61 online assessments.

Main Outcome Measures: University students (N = 168) retrospectively estimated correlations between physical activity, sleep, positive affect and stress over the seven-month study period.

Results: Correlations between experiences and behaviours (online data) were small (r = ?.12–.14), estimated correlations moderate (r = ?.35–.24). Correspondence between calculated and estimated correlations was low. Importantly, estimated correlations of physical activity with stress, positive affect and sleep were associated with actual engagement in physical activity.

Conclusion: Estimation accuracy of relations between health behaviours and experiences is low. However, association estimates could be an important predictor of actual health behaviours. This study identifies and quantifies estimation inaccuracies in health behaviours and points towards potential systematic biases in health settings, which might seriously impair intervention efficacy.